Caesarean most surgeons accept the idea that

Caesarean section (CS) becomesone of the commonest major surgical operations performed daily worldwide. 1However, gastrointestinal dysfunction has a major con­tributing role in theabdominal discomfort following CS as it can cause accumulation of intestinalsecretions and gases, resulting in nausea, vomiting, abdominal pain or distension.Thus, it can lead to prolonged postoperative hospital stay after CS.

2Postoperative ileus (POI),which is the worst form of intestinal dysfunction, leads to absoluteconstipation and oral intake intolerance. It is widely believed it can beresulting from a non-mechanical injury that disturbs the normal gastrointestinaltract motor activity. Also, most surgeons accept the idea that POI of anydegree is a predicted physiological and sometimes mandatory response to any openabdominal procedure. 3In the USA, POI is known tocost between $5000 and $10 000 which reaches a total of $1 billion annually dueto abdominal discomfort, hospital stay prolongation and high treatment costs. 4Thus, several techniques were tested as trials to enhance the gastrointestinalmotility resumption after CS. These include early oral intake, earlyambulation, chewing gum and coffee consumption.

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5, 6 The mechanism of enhanced postoperativegastrointestinal recovery by the chewing gum is believed to be due to stimulationof digestion through the cephalic-vagal pathway as it stimulates the severalneural and humoral factors that modulate the functions of different parts ofthe gastrointestinal tract. 2 Recently, a series of randomizedcontrolled trials were conducted to confirm the benefits of gum chewing in managinggastrointestinal dysfunction following CS. 7, 8 Their resultssuggested that gum chewing improved the early resumption of bowel functions andcan be implemented for enhanced recovery after surgery (ERAS) program. 2Our hypothesisTo assess theeffects of chewing gum to reduce the duration of postoperative ileus and toenhance postoperative recovery after a CS. This randomized controlledtrial was conducted at Armed Forces Hospital Southern Region, khamis Mushayt,Saudi Arabia in the period from April 2015 to June 2017 after being approved bythe local research ethics committee and prospectively registered (NCT02386748).The primary outcome measure was the time to first passageof stool, while secondary outcomes were the time of the first flatus, the firsthearing of normal intestinal sounds, the duration of hospital stay, theduration of parenteral therapy either intravenous antibiotics or fluids, thetime of initiation of breast feeding and the cost of hospital stay. Also, the secondary outcome measuresincluded tolerance of gum chewing, complications in all groups entailing febrile morbidity, bloodtransfusion, theoccurrence of vomiting, abdominal distension or postoperative paralytic ileusrequiring nasogastric tube placement or hospital re-admission.

Eligibilitycriteria: participant follow chart:600 women aged between 20 and35 years scheduled for elective CS; either first or repeated, with term,singleton, viable and healthy pregnancy were assessed for enrolment in thistrial. Our exclusion criteria were emergency caesarean section, multiplepregnancies, polyhydramnios, abnormal placentation (placenta praevia andoraccreta), and past history of medical disorders, bowel disease or gastrointestinaloperations. All eligible women were fully counselled about the trial potentialside effects before an informed written consent was signed by each participant.Randomization:400 eligible and consentedwomen were enrolled and divided randomly into three groups through sealedenvelope method which was withdrawn by the patient herself. Each envelope wasmarked with a serial number and had a card defines the intervention type. Onceparticipant had been allocated, it could not be changed. The ratio of one toone was determined as the allocation ratio during the allocation process. Thestudy nature did not allow blinding after application of the assigned intervention postoperatively.

Intervention:Women in group (A) receivedsugarless gum (Nova gum, Batook chewing gum IND. LTD, Saudi Arabia) two hoursafter their operating room (OR) discharge. They were instructed to chew it atleast for half an hour and at two hours interval during daytime.

Gum chewingwas stopped all over the night (12:00 PM) to allow the women to sleep. Countingand recording the number of empty sticks were done during the routine vitalsigns observations in order to assure the women’s compliance to gum use. Womenwere instructed to stop chewing gum with the passage of stool and they wereallowed to start regular oral intake.   Group (B) women started oralclear fluids after OR discharge by six hours. Group (C) was the control group;women of this group were kept on intravenous fluids for 24 hours, unlessresumption of intestinal function took place. Then, clear fluids and soft foodswere allowed orally to start with their first bowel motion. Intestinal soundsfor all groups were checked at six to eight hours intervals postoperatively bytwo of the authors (WA, MA).

 All the operations were performed in themorning under general anaesthesia using Pfennanstiel’s incision. The time whensurgery was ended discharging the woman from the operating theatre (OR) afterfull recovery marked as the zero hour. For analgesia, two rectal doses of 100mg diclofenac sodium(Voltaren, Novartis Pharma, Saudi Arabia), if not contraindicated. The need foradditional useof pethidine was recorded. No oral or rectal bowel stimulants were used after CS. The samepostoperative program for ambulation was used for all groups. Data collection:Women demographic data werecollected includingtheir age, body mass index (BMI), obstetric history, past medical and surgical histories,gestational age at delivery and caesarean section indications. The operative data were alsorecorded, including the operative time, need of blood transfusion, operative complications and thepresence ofsevere adhesions or uterine extension.

Moreover, the postoperative data like feeding time, timeof hunger feeling, time of passing flatus, time of passing stool, absent orhypoactive intestinal sounds,inability to pass flatus or stool, vomiting, abdominal distension with or without pain and tolerance of gum chewing were recorded. The criteria toconsider the woman fit for hospital discharge were stable vital signs for at least 24 hours, fullambulation without assistance, passage of a stool and urine, tolerance to solid food and absence ofpostoperative complications.Drop-outs:The women were followed tillthe final discharge from hospital and on outpatient basis. However, any events presented by the participantsduring the postpartum period were recorded.

Operative and postoperativeexclusion criteria were caesarean hysterectomy, extensive adhesions, uterineextensions, bowel injury and any operative complication that can affect the woman normal recoveryor plan of the trial. The past history and demographiccharacteristics were similar in all groups without any statistical significantdifference in the age, BMI, gestational age, past obstetric, medical andsurgical histories. The only operation rather than CS encountered in the pastsurgical history was appendectomy.The time of gastrointestinalrecovery was significantly shorter in group (A) as women included in this groupshowed statistically significant earlier onset of normal bowel sounds, passingflatus and stool. Table (2, 3) Also, they have significantly shorter durationof intravenous therapy and hospital stay as well as lower amount of intravenousfluids due to earlier resumption of regular oral intake. The operative time andthe need for intravenous pethidine showed no significant statistical differencebetween all groups. Although the abdominaldistension was exactly similar among gum chewing and conventional groups, theoccurrence of vomiting and PI was significantly higher in the later group. Onthe other hand, the only statistical significant difference noticed between theconventional and control groups was that fewer women suffered from abdominaldistension among the former group.

Otherwise, no other significant differenceswere detected. Table (4)


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